Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2018-2808
2. Registrant Information.
Registrant Reference Number: ProPharma Group case:# 1-52675400
Registrant Name (Full Legal Name no abbreviations): The Hartz Mountain Corporation
Address: 400 Plaza Drive
City: Secaucus
Prov / State: New Jersey
Country: USA
Postal Code: 07094-3688
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
05-JUN-18
5. Location of incident.
Country: CANADA
Prov / State: NOVA SCOTIA
6. Date incident was first observed.
26-MAY-18
Product Description
7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.
Active(s)
PMRA Registration No.
PMRA Submission No.
EPA Registration No. Unknown
Product Name: HARTZ ULTRAGUARD PRO FLEA & TICK TREATMENT FOR DOGS AND PUPPIES WEIGHI
- Active Ingredient(s)
- (S)-METHOPRENE
- D-PHENOTHRIN
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
Unknown
10. Site pesticide was applied to (select all that apply).
Site: Animal / Usage sur un animal domestique
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
Subform III: Domestic Animal Incident Report
1. Source of Report
Animal's Owner
2. Type of animal affected
Dog / Chien
3. Breed
Great Pyrenees
4. Number of animals affected
1
5. Sex
Male
6. Age (provide a range if necessary )
6
7. Weight (provide a range if necessary )
100
lbs
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
Unknown / Inconnu
11. List all symptoms
System
- Gastrointestinal System
- Symptom - Diarrhea
- Symptom - Vomiting
- Symptom - Loss of appetite
- Nervous and Muscular Systems
12. How long did the symptoms last?
Persisted until death
13. Was medical treatment provided? Provide details in question 17.
Unknown
14. a) Was the animal hospitalized?
Unknown
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Died
16. How was the animal exposed?
Treatment / Traitement
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
1-52675400 - The reporter, a pet owner, indicated his dog was exposed to an insecticidal spot-on product containing the active ingredients D-phenothrin and (S)-methoprene. Ten days before the day of initial contact with the registrant, the reporter placed the product on her 6-year-old, 100-pound, male, Great Pyrenees dog and later that night the dog developed diarrhea and vomited once. Eight days before the day of initial contact with the registrant, the dog lost his appetite and collapsed. Seven days before the day of initial contact, the reporter woke up to find the dog had died. The reporter was advised this is not an expected reaction to normal product use. No additional information is available.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Death
19. Provide supplemental information here